United States District Court, C.D. Illinois, Peoria Division
ORDER & OPINION
JOE BILLY MCDADE, Senior District Judge.
This matter is before the Court on Plaintiff's Motion for Summary Judgment (Doc. 11) and Defendant's Motion for Summary Affirmance. (Doc. 14). For the reasons explained below, Plaintiff's motion is denied and Defendant's motion is granted. The decision of the Administrative Law Judge (ALJ) to deny Plaintiff Social Security Disability benefits is affirmed.
I. Procedural History
On November 16, 2009, Plaintiff Rose Spencer applied for disability insurance benefits and Supplemental Security Income ("SSI") under Titles II and XVI of the Social Security Act, claiming that she had become disabled as of October 2006. (R. at 149-54). She said that she became disabled because of "bipolar disorder, learning disability, and blackout spells resulting in a fear of people, anger issues, difficulty sleeping, difficulty concentrating, and difficulty completing tasks." (R. at 83). The Social Security Administration initially denied her application on March 30, 2010. (R. at 79-83). Plaintiff filed for reconsideration on May 15, 2010 (R. at 84), and was again denied on August 4, 2010. (R. at 85-92). On September 3, 2010, Plaintiff requested a hearing before an ALJ. (R. at 95). ALJ Stephen M. Hanekamp held a hearing on April 12, 2012, in which Plaintiff, represented by her attorney, appeared and testified. (R. at 40-74). On June 26, 2012, the ALJ issued an opinion finding that Plaintiff was not disabled and thus not eligible for disability insurance benefits or SSI. (R. at 20-33). On August 21, 2012, Plaintiff requested that the Appeals Council review the ALJ's decision. (R. at 10). The Appeals Council denied Plaintiff's request for review on September 6, 2013, thereby making the ALJ's decision the final decision of the Commissioner of Social Security. (R. at 1-3). Plaintiff then filed her Complaint (Doc. 1) with this Court on October 17, 2013.
II. Relevant Medical History
Plaintiff is currently a twenty-nine year old woman with a ninth or tenth grade education, which she received through a special education program. (R. at 44). Her relevant medical history consists primarily of treatment at North Central Behavioral Health Systems, Inc. ("North Central"), where she was a patient of Dr. Scott Wright and Dr. Atul Sheth, and as of the filing of this lawsuit, has been a client of Licensed Clinical Professional Counselor Pam Helms. (R. at 432, 469, and 741-67). According to Plaintiff's treatment notes from North Central, Plaintiff has also received treatment from Gretchen Fawcett, a physician's assistant. ( See, e.g., R. at 716, 722). However, the record does not contain records of Plaintiff's treatment from Ms. Fawcett. The record also contains treatment records from McDonough District Hospital, where Plaintiff was admitted on December 2, 2009 after she walked in front of a large truck while under the influence of alcohol. (R. at 507-62).
Plaintiff was also evaluated by four non-treating sources who are relevant to this action: Mario Di Biase, Psy. D., Frank Froman, Ed. D., Jeanne Yakin, Ph.D., and Joseph Mehr, Ph.D.
For ease of review, this Order and Opinion reviews records from Plaintiff's treating sources before reviewing records from Plaintiff's non-treating sources, even though this slightly disrupts the chronological order of Plaintiff's treatment history.
A. Plaintiff's Treating Sources
Beginning in April of 2008, Plaintiff began receiving treatment from North Central Behavioral Health Systems, Inc., (R. at 414), where she continued meeting with clinical staff through the pendency of her social security application and appeal. ( See R. at 741-767 (medical records from North Central from June 27, 2011 through March 2, 2012)). Plaintiff had been sentenced to thirty-months of probation for possession of cocaine (R. at 416), and began receiving treatment at North Central at the request of her probation officer. (R. at 414).
Pam Helms conducted Plaintiff's initial psychosocial assessment. (R. at 419). Plaintiff stated to Helms that "she has a problem with marijuana, " and said she smokes it because "it helps her relax and she has a lot of anger and anxiety." (R. at 414). At the time, she reported that her children were living with her father. (R. at 415). During the assessment, Plaintiff "was very guarded." (R. at 421). She reported "that she has always been in trouble with the law and feels authority figures pick on her." She said that she felt that "if she ha[d] the right medication she would not need to smoke pot." Helms noted that during the intake, Plaintiff was oriented to time, place, person, and situation, and had an appropriate facial expression, dressed appropriately, and appropriate affect. (R. at 420). She had increased motor activity with pressured speech, and had fair insight but poor judgment. ( Id .).
Plaintiff returned to North Central on July 28, 2008 for a psychiatric evaluation conducted by Dr. Scott Wright. (R. at 432). Plaintiff complained about the fact that she "can't hold down a job because she has anger outbursts and then quits abruptly, " among other things. ( Id. ). She complained that she has "more bad days than good days, " and said her moods are more "irritable and angry than sad, and more sad than nervous." ( Id. ). Dr. Wright diagnosed her with bipolar affective disorder, intermittent explosive disorder, marijuana abuse, and alcohol abuse. (R. at 433). He prescribed Lamictal, to be taken twice a day. (R. at 434).
Plaintiff stopped treatment in September 2008 after attending two counseling sessions because she was incarcerated. (R. at 438). Her case notes indicate that she had stopped taking Lamictal. ( Id. ).
She returned for treatment in July of 2009. (R. at 450). At that time, she was not under a doctor's care and was not taking medication. (R. at 451). The intake notes indicate that Plaintiff received support from her family and was able to maintain a residence and obtain or maintain employment. (R. at 452-53). She experienced discomfort in social situations and difficulty in forming and maintaining relationships. (R. at 453). According to the report, she said "she would like to find a medication and treatment that will help her with her anger and mood swings." (R. at 455). Helms noted that Plaintiff "seems more mature and ready for treatment." ( Id. ).
On August 27, 2009, Plaintiff had an initial psychiatric visit with Dr. Atul Sheth at North Central. (R. at 469-78). He diagnosed Plaintiff with mood disorder, intermittent explosive disorder, signs of bipolar disorder, and borderline personality disorder. (R. at 477). He prescribed a daily 15 milligram dose of Abilify, an anti-psychotic meant to treat symptoms of schizophrenia and bipolar disorder, and a daily 100 milligram dose of Trazodone, an anti-depressant meant to treat depression and sleep disturbances. (R. at 479-80).
Plaintiff returned to North Central on October 19, 2009 for a routine follow-up. The treatment notes reflect that she blamed all of her symptoms on Abilify. (R. at 488). At that time, Dr. Sheth reported that her "symptoms are somewhat better." (R. at 489). Dr. Sheth prescribed Depakote, an anti-convulsant, to be taken twice-daily - 250 milligrams in the morning and 500 milligrams in the evening - for mood stabilization. (R. at 492). She began taking clonidine on October 28, 2009. (R. at 498). At an appointment on November 16, 2009, Dr. Sheth reported that Plaintiff was not compliant with her medication, "blames all symptoms on Abilify, " "took one dose of depakote, " and was "not taking clonidine." (R. at 499). Even so, he noted that her symptoms were somewhat better. (R. at 500). Dr. Sheth took Plaintiff off of Abilify, prescribed Elavil, and kept Plaintiff on Clonidine, and Trazodone. (R. at 503-504).
On December 2, 2009, Plaintiff was admitted to McDonough District Hospital, where she was discharged on the same day. (R. at 508). At discharge, the hospital diagnosed her with alcohol intoxication and a possible suicide attempt. ( Id. ). Plaintiff arrived at the hospital with a blood alcohol level of 0.27%. Police told hospital staff that she "tried to walk out in front of a semi and they felt that she was doing this on purpose." ( Id. ). The hospital admitted Plaintiff into the Intensive Care Unit and monitored her until her blood alcohol level was 0.0%. ( Id. ). Once Plaintiff was sober, she denied that she was trying to hurt herself. ( Id. ).
Plaintiff returned to North Central on March 4, 2010 to meet with Helms. (R. at 601-02). Helms noted that "Rose continues to have mood swings, issues with anger, and is easily frustrated. This makes it very difficult for Rose to maintain employment..." (R. at 602). She noted that several of the medications Plaintiff's doctors prescribed cause side effects. ( Id. ). Plaintiff met with Dr. Sheth on April 19, 2010. (R. at 603-08). At that time, Dr. Sheth took Plaintiff off of Elavil, Clonidine, and Trazodone, and prescribed Remeron. (R. at 604, 612-13). Again, he noted that Plaintiff's symptoms were somewhat better. (R. at 605). Plaintiff had a routine follow-up with Dr. Sheth on July 19, 2010. Dr. Sheth noted that Plaintiff was still having trouble sleeping, but also noted that Remeron helped her mood. (R. at 658). He prescribed Vistaril (R. at 664).
On July 12, 2010, Helms completed a Psychosocial Assessment. (R. at 641-53). The assessment noted that Plaintiff's "current living situations/strengths" included caring for her own nutritional needs, cooking, using the post office, caring for her own grooming or hygiene, caring for her own medical needs, housekeeping, shopping, and using the telephone. (R. at 644).
On August 26, 2010, Helms noted that "Rose continues to have mood swings, issues with anger, and is easily frustrated. This makes it very difficult for Rose to maintain employment. She has difficulty getting aloing [sic] with others and has short term relationships. I have closed Rose to substance abuse but she is remaining in treatment for bipolar disorder." (R. at 663).
On October 11, 2010, Plaintiff met with Dr. Sheth for a routine follow-up. During this appointment, both Plaintiff and Dr. Sheth noted that her symptoms were somewhat better. (R. at 665). He increased her dosage of both Remeron and Vistaril. ( Id. ). Plaintiff stopped taking her medications in November 2010, once she learned that she was pregnant. (R. at 670). Her OB/GYN prescribed Wellbutrin "and something to help her sleep" shortly thereafter. (R. at 671).
Plaintiff continued to meet with Helms during her pregnancy. On December 29, 2010, Helms conducted a Level of Care assessment and concluded that Plaintiff had a serious impairment in her level of care with respect to her functional status. Specifically, the report noted "[s]erious deterioration of interpersonal interactions with consistently conflictual or otherwise disrupted relations with others, " and "inability to perform close to usual standards in school, work, parenting, or other obligations." (R. at 684-85). Later, in July 2011, Helms upgraded Plaintiff's functional ability from serious to moderate, and noted "significant deterioration in ability to fulfill responsibilities and obligations to job..." (R. at 694).
Plaintiff began seeing Gretchen Fawcett, a physician's assistant, in September 2011 (R. at 716). At that time, she was still only taking Wellbutrin. Helms consulted with Fawcett about Plaintiff's medication on December 12, 2011. (R. at 722). Helms's notes reflect that Plaintiff began taking Effexor on December 21, 2011. (R. at 723). Although these notes to do not reflect that Fawcett also prescribed Xanax, later notes suggest that she did. ( See R. at 754). The notes also reflect that Dr. Sheth was no longer treating Plaintiff at that time. ( Id. ). Helms's case notes reflect that Plaintiff benefited the Xanax and Effexor. ( Id. ). In January 2012, Plaintiff said she was compliant with her medications and they were "really helping her stay calm." ( Id. ).
As part of Plaintiff's application for benefits, Helms submitted two identical Medical Source Statements - the first dated December 13, 2010 (R. at 673-75), and the second on March 2, 2012. (R. 679-81). In them, Helms opined that Plaintiff's ability to understand, remember, and carry out instructions and her ability to interact appropriately with supervisors, co-workers, and the public were affected by her impairments in a number of marked and extreme ways. ( Id. ). Helms identified Plaintiff's diagnoses of intermittent explosive disorder, bipolar disorder, and manic borderline personality disorder, explained that Plaintiff is easily frustrated, has anger outbursts, does not trust others, and has an inability to both take orders and work alone. ( Id. ). She based her opinion on "numerous therapy sessions." ( Id. ).
B. Plaintiff's Non-Treating Sources
Plaintiff was also evaluated by four relevant non-treating sources as part of her various applications for benefits.
1. Mario Di Biase, Psy. D.
Plaintiff was evaluated by Mario Di Biase, Psy. D. on March 14, 2003, as part of a previous application for benefits. (R. at 304-310). She reported to Dr. Di Biase that she had "long standing problems with attention and concentration, and she noted that she carries a diagnosis of Attention Deficit Hyperactivity Disorder." (R. at 304). She also said that she "feels depressed a lot" and "experiences problems with sad mood, tearfulness, sleeping, low self-esteem, decreased energy, poor appetite, and social isolation." ( Id. ). At the time, she was not taking any medication, although she had previously taken Ritalin. ( Id. ). She reported that she was "independent for her activities of daily living." (R. at 305). She said she spent most of her time caring for her son and some of her time watching television. She also said she helps her mother with grocery shopping. ( Id. ).
Dr. Di Biase conducted a number of tests, and concluded that her "overall level of intellectual functioning [fell] within the Low Average Classification." He also concluded that her presentation was "suggestive of Dysthymic Disorder." (R. at 309-310).
2. Frank Froman, Ed. D.
As part of a more recent previous application for benefits, in which she complained of depression and learning disabilities, Frank Froman, Ed. D. conducted a Mental Status Examination of Plaintiff. (R. at 378). Plaintiff complained "about feeling anxious around others, " and said she often feels paranoid. (R. at 380). At the time, she was not taking medication. Dr. Froman noted that she was "casually and neatly attired...Hygiene was adequate." (R. at 378). During the consultation, Plaintiff reported periodic episodes of feeling like she was going to pass out, and also reported one seizure. ( Id. ). Dr. Froman observed that she "related in a somewhat anxious manner." She had a "fairly good" ability to relate and had "a sense of hypomania about her. Her speech was voluminous, with a great many asides." (R. at 379).
Plaintiff reported to Dr. Froman that she often cut herself when she was younger and still feels tempted to do the same. ( Id. ). She said she socializes "with some friends, all of whom are bipolar.'" ( Id. ). She said that she sleeps "a great deal, " including sleep at unusual times. ( Id. ). At the time she said that she was working at the Village Inn in Quincy, Illinois, but feared she would lose her job because she lost her car and had no way of traveling to work. ( Id. ). During the day, she said she does routine chores. ( Id. ).
Dr. Froman oriented Plaintiff three times and concluded that she was "in good contact with reality." ( Id. ). She was able to conduct certain math processes, but not others, and she could explain analogies and idioms. (R. at 379-80).
Dr. Froman diagnosed Plaintiff with Social Anxiety Disorder, ADHD, and Borderline Personality Disorder. (R. at 380). He identified Plaintiff's current stressors as "lack of transportation; money; unresolved mental health issues - moderately severe." ( Id. ). He concluded that she was "quite able to perform one and two step assemblies at a competitive rate, " but limited her to "being only with a few" co-workers and supervisors because "[s]he becomes readily overwhelmed when she is around too many people." ( Id. ) He wrote ...